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Ask the Expert
by Leonard Roberts, M.D.
What do I
need to know about
Breast Cancer?
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Breast
cancer is on the rise, with as many as 175,000 new
cases every year. There are many known risk factors
for breast cancer.
Risk Factors
Heredity looms large as a risk factor. In fact,
15% of new breast cancer cases have a family history
in a first degree relative. Race is a factor, as
well, as the incidence is lower among asians and
blacks.
Age at the first pregnancy influences the incidence.
Women who have their first baby under the age of
18 have a somewhat reduced risk when compared to
women who have a first baby after age 35. Women
who have never been pregnant are also at an increased
risk.
Menstrual history is important, as women who begin
menstruating at a young age or begin menopause late,
are at an increased risk for breast cancer.
There is some controversy as to whether oral contraceptive
pills increase the incidence of breast cancer. A
recent study showed there was an increase in lobular
breast cancers, but in a decrease in ductal breast
cancer in women who used combined oral contraceptives
for at least six months.
A
diet high in fat may also be associated with an
increased incidence of breast cancer, and the role
of fat in the production of estrogen is well recognized.
There is no reliable correlation between smoking,
alcohol or caffeine as risk factors for breast cancer.
By
far the most common cause of a palpable mass in
the breast is fibrocystic change. There is an incidence
of fibrocystic breast changes of approximately 10%
in women under the age of 21, which rises to 25%
in women in their menstrual years, and then rises
to 30 to 50% in women in their pre-menopausal years.
These women experience pain and tenderness, usually
in both breasts which can vary at different times
in their menstrual cycles. Other palpable benign,
or noncancerous findings may be fibro adenomas,
breast cysts or traumatic fat necrosis.
Signs and Symptoms
A lump or a mass is a significant finding which
may be sign of breast cancer and should be reported
to your doctor immediately.
Other
signs and symptoms include a change in symmetry
or size of the breast, changes in the skin on the
breast such as thickening, dimpling, or scaly skin
around the nipple, an orange peel like appearance
or ulcers or inversion of the nipple.
You
should report changes in the skin temperature or
color, such as a warm hot or pink area to your doctor
as well. Unusual drainage or discharge from
the breast may also be a significant sign and symptom
of breast cancer, as can be a change in the nipple,
such as itching, burning, erosion or protrusion.
Finally, pain is a significant
finding and may be indicative of an advanced
tumor.
Diagnosis
The earlier breast cancer is found the higher
the cure rate. A breast mass may first be
found by either a physician or a patient.
All women should perform a complete monthly
self examination, including inspection and
palpation of all parts of the breast. The
best time to perform a breast self examination
is seven to ten days after the start of your
period.
The
first step in performing a breast self exam
is to stand in front of a mirror and compare
both breasts, checking for unusual signs such
as discharge from nipples, puckering, dimpling,
scaling of the skin or changes in size or
shape. Then, raise your arm and use the fingers
of your other hand to feel your breast carefully
and slowly. Begin at the outer edges, pressing
in small circles moving around the entire
breast. Be certain to examine the entire breast,
from your arm pit to the collar bone and below
your breast.
Thereafter
gently squeeze the nipple and check for discharge.
Repeat this on the other side thereafter.
In
the event that you feel a mass or a lump in
your breast you should notify your doctor
immediately. Since a mass that you can feel
may either be benign or malignant, testing
is essential. The most common test used by
doctors is mammography, which is used to detect
lesions in their earliest stages.
Mammography may detect tumors that are very
small, even too small to be detected during
an examination of the breast.
A
mammogram is an x-ray of the breast which
may detect tumors, and is recommended once
between ages of 35 and 40, or earlier if there
is a strong family history. Between ages 40
and 50 a mammogram should be performed every
1-2 years. After the age of 50 women should
have a mammogram every year.
Even though mammograms
are highly useful in detecting cancer of the
breast, as many as 10% of occult cancer of
the breast remain undetected by mammograms,
or by the complimentary use of sonogram.
If
the mammogram is reported as negative, but
the mass or lump continues to be present,
a biopsy may be needed. A biopsy is a procedure
which involves obtaining tissue from the breast
so it can be sent to a lab for analysis. Some
biopsies can be done using a fine needle to
draw fluid out of the site of a lump, but
at other times the procedure must be done
in the operating room. A negative needle biopsy
and a persistent mass requires an incisional
biopsy for accurate diagnosis.
Treatment
More
and more in our society there is an identification
with emininity, sexuality and self image
connected with the breast. Many women feel
that a mastectomy, or removal of the breast,
will depreciate their femininity and impact
their sexuality and, as a result, when faced
with the various treatment options depression
can be a significant problem. Early diagnosis
is extremely important, as this gives a better
success rate and may minimize the extent of
surgery needed. Plastic surgical restoration
may be successful, and may be considered in
planning the course of therapy.
There are several types of surgical treatment
available, depending on the extent and type
of cancer. For small, well defined cancers
a lumpectomy which removes the tumor and some
of the surrounding tissues may be performed.
A
surgeon may also perform a partial mastectomy,
a total mastectomy or a modified radical mastectomy.
Evaluating the axillary lymph nodes, which
are located in the armpit is a part of all
these procedures.
To prevent reoccurrences of breast cancer,
x-ray therapy or chemotherapy may be indicated.
Use of Tamoxifen, a hormone based drug, may
be recommended by your doctor.
Breast cancer is the most common form of cancer
in women. The survival rate has improved but,
as with any cancer, early diagnosis is the
key to a good outcome.
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